Pre Background Questionnaire Form – Fill Out and Use This PDF

The Pre Background Questionnaire Form is a powerful tool for gaining faster and more insightful information about prospective candidates. As part of the hiring process, it allows employers to ask detailed questions that help determine qualifications, work preferences, and trainability quickly and accurately. This questionnaire covers topics such as educational background, past employment history, certification requirements, and other relevant questions that can uncover nuances from folks looking to join your organization. By tapping into the talents already in you current Organization or unearthing previously unknown talents within new employees you can gain a wealth of knowledge related to how they best fit your team and its needs or goals. Ultimately this shortened version of a potential candidate interview will save everyone valuable time while garnering highly the specific details necessary for making educated decisions during recruitments.

Pre Background Questionnaire Form PDF Details

When creating personal records or conducting research, it is important not to overlook the importance of data collection and analysis. Utilizing a pre background questionnaire form allows individuals or teams to quickly gather the necessary information in one place, allowing them to start their project off right and get on with their business efficiently. Knowing how to ask the right questions, select appropriate methods for collecting data, analyze results correctly and use this knowledge effectively is essential for any team engaged in any kind of project. In this blog post we will explore what types of questions can be included in a pre-background questionnaire form as well examining why they are so useful and beneficial.

Question	Answer
Form Name	Pre Background Questionnaire Form
Form Length	17 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 15 sec
Other names	pre background interview questionnaire, BEASTIALITY, san pre questionnaire, telework questionnaire

Form Preview Example

SAN BERNARDINO COUNTY SHERIFF’S DEPARTMENT PRE-BACKGROUND INTERVIEW QUESTIONNAIRE

Date: ______________________ Position Applied for: __________________________________

Name: _______________________________ Social Security Number:_____________________

LastFirst

Date of Birth:________________ Driver’s License Number: _________________ State:______

Address: _____________________ City: _________________ State: ______ Zip Code: _______

Telephone: ____________________	_____________________	_____________________
Home	Cell	Work

E-Mail Address(s): _______________________________________________________________

How did you hear about the San Bernardino County Sheriff’s Department?			(Check One)
County Human Resources	Department Member	Advertisement	Job Fair

Sheriff’s Website

Other:

As an applicant for a position with the San Bernardino County Sheriff’s Department, you are required to complete this background questionnaire. This questionnaire supplements your Personal History Statement (PHS) or application, which will be treated in the same manner.

Pursuant to the Americans with Disabilities Act (ADA), you are not required nor are you expected to furnish any information in this questionnaire that is of a medical nature. For example, do not report any work absences for illness or workers compensation claims. Do not discuss or report any disabilities you might have. This information is strictly medical in nature, and as this questionnaire is part of the pre-job offer background investigation, is not subject to disclosure during this portion of the background investigation.

For the purpose of this questionnaire, drug possession shall be defined as each time the drug was in your personal possession either on or within the body or in the hands, clothing, vehicle, home, residence or any other area that you controlled.

Please read and answer all of the questions. You are admonished to answer all questions completely and truthfully. If you are dishonest in your answers, fail to fully answer any question, or misstate any material facts, you will be disqualified from further consideration for this position. Remember that your response may be subject to verification by a polygraph examination.

PRE-BACKGROUND INTERVIEW QUESTIONNAIRE.doc

BACKGROUND INTERVIEW QUESTIONNAIRE

INSTRUCTION SHEET

Carefully read and answer each question.

If you answer “YES” to any question, you must write a complete explanation in handwriting on the blank sheets attached (use additional paper if needed).

Print only using black ink.

All written responses must be answered completely, accurately and truthfully. (Provide dates, locations, amounts, etc.)

Write the corresponding question number adjacent to the written explanation.

After completing each page, you must initial the bottom right corner of each page.

In accordance with the Americans with Disabilities Act (ADA), do not list any medical related information or history about yourself on this questionnaire or any attached pages.

Vague, ambiguous, misleading, illegible or unanswered responses may be cause for disqualification from further consideration.

If you see the word “ever” in any question that means your entire lifetime.

San Bernardino County Sheriff’s Department employees must be able to read, interpret, comprehend, and complete police reports, forms and other documents accurately and in a timely manner. For this reason, in addition to evaluating your moral character and suitability, we will evaluate your ability to complete this questionnaire accurately. Your ability to write clear statements, which accurately describe an occurrence, will be evaluated.

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ADVISEMENT TO APPLICANT

The purpose of a pre-employment background investigation, for all intents and purposes, is to verify that the application you have submitted and any statements you have made to the San Bernardino County Sheriff’s Department, concerning your qualifications, are true.

The California Courts have held that an employer has a legal duty to know the persons whom it employs. In some cases, California law may mandate a background investigation before employment, while in other cases it is merely a case of public policy or prudence before placing someone in a position of public trust.

Both State and Federal Courts have also held that there is an absolute necessity for public employees to be truthful. You must understand that a lack of truthfulness or deception of any type on your part will automatically and irrevocably result in your application being rejected from further consideration.

For some people, there may be one or more incidents or occurrences in their background which they regret or over which they may feel some embarrassment. A prospective employer will not make inquiries into areas of a person’s background which have no legitimate bearing on their qualifications for the job. However, you should understand that the mere presence of so-called “negative” information in your background is not automatically disqualifying. For example, an applicant may have engaged in petty thievery as a child, have used illegal drugs, may have been fired from a job or even have been convicted of a crime as an adult. While these things, in and of themselves, may not automatically remove that person from consideration for a job, lying about them will.

A pre-employment background investigation is not intended to be an intimidating experience or an unwarranted invasion into your privacy. Your background investigator will contact persons who know you, including present and/or former employers, and will examine official documents and records concerning you to assure that you have been honest in your application in order to fulfill the legal mandates imposed by the Courts and the Legislature. The more forthright you have been, the greater the likelihood that your background can be completed in a timely and successful manner.

CERTIFICATION

I understand that any false statements and/or deliberate misrepresentations, whether by omission or commission, will result in my application being automatically and irrevocably rejected from further consideration. I certify that I have read the above statement, understand its contents and have been furnished a copy of it.

Dated this______day of________________, 20___, in the County of San Bernardino, State of California.

___________________________________	___________________________________
Signature of Applicant	Signature of SBSD Agent

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PERSONAL DATA

1.	Do you use, or are you known by any other names, or monikers, or aliases?	Yes	No
1.
2.	Have you ever impersonated another person?	Yes	No
2.
3.	Have you ever impersonated a police officer?	Yes	No
3.

FINANCIAL STATUS

4.	Have you ever provided false information on a credit or loan application?	Yes	No

5.	Have you ever had a poor credit rating?	Yes	No

6.	Have you ever been refused credit?	Yes	No

7.	Have you ever been evicted or threatened with an eviction process?	Yes	No

8.	Have you ever been sued over a debt?	Yes	No

9.	Have you ever filed for debt reorganization?	Yes	No

10.	Have you ever written a check knowing funds were not available to cover payment?	Yes	No

11.	Have you ever bounced a check? If so, what did you do about it?	Yes	No

12.	Have you ever had a debt turned over to a collection agency?	Yes	No

13.	Have you ever been late paying rent or a mortgage payment?	Yes	No

14.	Has your salary ever been attached for non-payment of debts?	Yes	No

15.	Have you ever avoided paying any lawful debt by moving away?	Yes	No

16.	Have you ever been late paying your taxes?	Yes	No

17.	Have you ever failed to support any child of yours?	Yes	No

18.	Have you ever been late in repaying a student loan?	Yes	No

19.	Have you ever filed a false insurance claim?	Yes	No

20.	Have you ever-obtained financial gain through dishonest means?	Yes	No

21.	Have you ever collected unemployment or welfare benefits (including food stamps)	Yes	No
21.	when you were not entitled?	Yes	No
	when you were not entitled?
22.	During your background investigation, is anyone likely to report that you have or	Yes	No
22.	had financial problems?	Yes	No
	had financial problems?
23.	Have you ever filed Bankruptcy or Chapter 13 relief?	Yes	No

24.	Have you ever falsified any information on a Bankruptcy Petition?	Yes	No

25.	Have you ever had any property, including a vehicle, repossessed?	Yes	No

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MILITARY (IF APPLICABLE)

26.	Did you ever fail to register for the military draft when required to do so by law?	Yes	No

27.	Are you concerned about an investigation into your military record?	Yes	No

28.	Have you ever been denied enlistment or re-enlistment in the military service?	Yes	No

29.	Were you discharged from the military in any way other than honorable?	Yes	No

30.	Have you ever been considered absent without leave (A.W.O.L.) or taken an	Yes	No
30.	unauthorized absence from the military?	Yes	No
	unauthorized absence from the military?
31.	Were you ever restricted to the base?	Yes	No

32.	Were you ever in military confinement?	Yes	No

33.	Were you ever court-martialed or subject to an administrative discharge board?	Yes	No

34.	Did you ever receive non-judicial punishment, non-judicial office hours, Captain’s	Yes	No
34.	Mast, or similar punishment?	Yes	No
	Mast, or similar punishment?
35.	While in military, did you receive any type of disciplinary action?	Yes	No

36.	While in the military, were you ever reduced in grade or rank?	Yes	No

37.	During your background investigation, is anyone likely to report that you had any	Yes	No
37.	other problems while in the military?	Yes	No
	other problems while in the military?
38.	Did you ever use deadly force while in the military?	Yes	No

TRAFFIC/VEHICLE OPERATION

39.	Has your driver’s license ever been suspended or revoked?	Yes	No

40.	Have you ever received a traffic citation, other than for parking?	Yes	No

41.	Have you ever had a traffic citation that did not show on your DMV record?	Yes	No

42.	Have you ever had a traffic citation go to warrant? If yes, include dates and county	Yes	No
42.	where original violation took place.	Yes	No
	where original violation took place.
43.	Are you currently driving without automobile insurance? If yes, for how long?	Yes	No

44.	Have you ever driven an uninsured vehicle? If yes, please give specific time frames.	Yes	No

45.	Have you ever been denied vehicle insurance?	Yes	No

46.	Have you ever been placed on probation for a traffic-related offense?	Yes	No

47.	Have you ever been involved in a police pursuit?	Yes	No

48.	Have you ever fled the scene of a traffic accident?	Yes	No

49.	Have you ever caused anyone serious injury or death by your operation of a motor	Yes	No
49.	vehicle?	Yes	No
	vehicle?
50.	Have you ever driven a vehicle without a valid drivers license?	Yes	No

51.	As a driver, have you ever been involved in a traffic collision? If yes, explain (give	Yes	No
51.	dates, locations, whether you were at fault)	Yes	No
	dates, locations, whether you were at fault)

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PERSONAL CONDUCT

52.	Have you ever been arrested for an illegal sex act?	Yes	No

53.	Have you received payment for or have you paid for sexual acts?	Yes	No

54.	Have you ever illegally exposed your genitals?	Yes	No

55.	Have you ever had to register as a sex offender?	Yes	No

56.	Have you any reason to be concerned about an investigation into your personality	Yes	No
56.	traits?	Yes	No
	traits?
57.	Do you have any prejudices against any minority, religious, or militant groups?	Yes	No

58.	During your background investigation, is anyone likely to report that you have any	Yes	No
58.	prejudices against any minority, religious, or militant groups?	Yes	No

59.	Do you feel your prejudices might affect your ability to perform this job?	Yes	No

USE OF INTOXICANTS

60.	Have you ever been detained or arrested for driving under the influence of an	Yes	No
	intoxicant?

61.	Have you ever driven a vehicle under the influence of alcohol and/or drugs? If so,	Yes	No
	give the date of the last occurrence.

GAMBLING

62.	Have you had any family problems because of gambling?		Yes	No

63.	Have you had any employment problems because of gambling?		Yes	No

64.	Have you ever placed an illegal bet on a sporting event?		Yes	No

65.	Have you ever gambled while delinquent or behind in your financial obligations?		Yes	No

66.	Have you gambled in the last year?		Yes	No

67.	Have you ever borrowed money to gamble with?		Yes	No

68.	What is the most you have ever lost by gambling and won by gambling?		Yes	No
68.	Total Losses:	Total Winnings:	Yes	No
	Total Losses:	Total Winnings:

EMPLOYMENT HISTORY

69.	Have you ever called in sick when you were really well? If yes, why?	Yes	No

70.	Have you ever had any difficulty with a co-worker, subordinate, or supervisor?	Yes	No

71.	During the course of your employment, have you ever had a complaint made against	Yes	No
71.	you?	Yes	No
	you?
72.	Has any teacher or supervisor (including military) ever spoken to you about being	Yes	No
72.	tardy or absent too often?	Yes	No
	tardy or absent too often?
73.	Have you ever been in a fight (verbal or physical) with a co-worker, supervisor,	Yes	No
73.	teacher, or customer of an organization you were working?	Yes	No
	teacher, or customer of an organization you were working?
74.	Have you ever been accused of misconduct at a place of employment?	Yes	No

75.	Are you concerned about an investigation into your past work history?	Yes	No

76.	Were you ever fired from a job? If yes, please include employers and dates.	Yes	No

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77.	Were you ever asked to resign from a job? If yes, include employers and dates.	Yes	No

78.	Did you ever resign from a job to avoid being fired?	Yes	No

79.	Have you ever left a job without giving proper notice?	Yes	No

80.	Have you been disciplined by an employer?	Yes	No

81.	Are there any reasons for you not showing true and complete explanation(s) for	Yes	No
81.	leaving each of your previous jobs?	Yes	No
	leaving each of your previous jobs?
82.	Have you ever left a job with hard feelings toward the management or co-workers?	Yes	No

83.	Are there any reasons you could not return to work for all of your former	Yes	No
83.	employers?	Yes	No
	employers?
84.	Have you ever stolen any money from a place where you worked?	Yes	No

85	During your background investigation, is anyone likely to report derogatory	Yes	No
85	information about your work performance?	Yes	No
	information about your work performance?
86.	Have you ever borrowed money from an employer with or without their permission	Yes	No
86.	and not paid it back?	Yes	No
	and not paid it back?
87.	Have you ever been over paid by an employer and not reported it?	Yes	No

88.	Have you ever embezzled any money from an employer?	Yes	No

89.	Have you ever stolen, given away or discounted any merchandise or property from	Yes	No
89.	any employer?	Yes	No
	any employer?
90.	Have you ever stolen any merchandise or property from an employer?	Yes	No

91.	Have you ever taken any property that didn’t belong to you from a place where you	Yes	No
91.	worked? If yes, include name of employer.	Yes	No
	worked? If yes, include name of employer.
92.	During your background investigation, is anyone likely to report that you have	Yes	No
92.	stolen something from a place where you worked?	Yes	No
	stolen something from a place where you worked?
93.	Have you ever been accused of sexual harassment? If yes, was there an	Yes	No
93.	investigation conducted?	Yes	No
	investigation conducted?
94.	Has a bonding company ever turned you down?	Yes	No

95.	Have you ever filed a false worker’s compensation claim?	Yes	No

GOVERNMENT APPLICATIONS

96.	Have you ever previously applied to the San Bernardino County Sheriff’s	Yes	No
96.	Department for a sworn and/or civilian position?	Yes	No
	Department for a sworn and/or civilian position?
97.	Have you ever applied to another law enforcement agency?	Yes	No

98.	Have you ever been rejected by this or any other law enforcement agency for any	Yes	No
98.	reason?	Yes	No
	reason?
99.	Have you ever worked at this or any other law enforcement agency in any capacity?	Yes	No

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CRIMINAL BEHAVIOR/LAW ENFORCEMENT CONTACTS

100.Have you ever committed any of the following?

A. ARSON (unlawfully set fire)		Yes	No

B. BURGLARY (entry of a structure or vehicle to commit theft or any felony)		Yes	No

C. ROBBERY (theft from another person using a weapon or force)		Yes	No

D.	HOMICIDE / MANSLAUGHTER	Yes	No

E. THEFT (including switching price tags, shoplifting)		Yes	No

F.	FORGERY	Yes	No

G.	KIDNAPPING	Yes	No

H.	EXTORTION (blackmail)	Yes	No

I. EMBEZZLEMENT (theft of money or other valuables entrusted to you)		Yes	No

J. RAPE (sexual intercourse by force, threat, alcohol or drug, including your spouse)		Yes	No

K. ANY SEX ACT WITH A PERSON UNDER AGE 18		Yes	No

L.	INCEST (sexual intercourse with a member of your immediate family, other than	Yes	No
L.	your spouse)	Yes	No
M. SEX IN A PLACE EXPOSED TO PUBLIC VIEW		Yes	No

N.	VIOLENT ASSAULT UPON ANOTHER PERSON (including spouse, significant	Yes	No
N.	others)	Yes	No
O. DOMESTIC VIOLENCE (including spouse, common-law, significant others):
	1. Have you ever assaulted another person in a dating relationship or during the	Yes	No
	relationship’s termination?
	2. Have you ever committed any act of physical violence (i.e. slapping, hitting,
	beating, arm-twisting, spitting, etc.) within an intimate relationship	Yes	No
	(including casual and long-term relationships)?
P.	CHILD/ELDER ABUSE:
P.	1. Have you ever neglected the care of a child or elderly person who was your
		Yes	No
	responsibility (i.e. did not feed, clean, clothe, or take care of medical needs	Yes	No

	as deemed appropriate, etc.)?
Q.	CHILD MOLESTATION (any sex act with a child)
Q.	1. Have you ever had sexual contact with a child (i.e. fondling, taking
		Yes	No
	pornographic pictures, masturbating in a child’s presence, sexual acts, sexual	Yes	No

	intercourse)?
R. BEASTIALITY (any sex act with an animal)		Yes	No

S.	PROSTITUTION OR OTHER ILLEGAL SEXUAL ACTS (intercourse or other	Yes	No
S.	sexual acts for money or other considerations)	Yes	No
	sexual acts for money or other considerations)
T.	SOLICITING PROSTITUTION (asking for sex in exchange for money or other	Yes	No
T.	considerations)	Yes	No
	considerations)
U.	VANDALISM (illegally damaged or destroyed property or committed any act of	Yes	No
U.	malicious mischief)	Yes	No
	malicious mischief)
V.	PUBLIC INTOXICATION	Yes	No

W.	COMPUTER CRIMES (fraud, identity theft, or false impersonations, cyber sex,	Yes	No
W.	child pornography, solicited sexual acts from a person under 18 years old).	Yes	No

101. Have you ever carried a concealed weapon without a permit to do so?		Yes	No

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102	Are you prohibited by law from owning, possessing, or carrying a firearm?	Yes	No

103.	Have you ever applied for a permit to carry a concealed weapon?	Yes	No

	Have you ever illegally carried a weapon? (Includes any dagger, billy club, metal
104.	knuckles, nunchaku, throwing star, sap, short-barreled shotgun/rifle, butterfly knife,	Yes	No
	or any explosive substance.)
105.	During your background investigation, is anyone likely to report that you have	Yes	No
	illegally used or carried a firearm?
	Either as an adult or juvenile, have you ever been questioned or detained by any law
106.	enforcement agency during an investigation? (Detention in and of itself is not	Yes	No
	disqualifying.)
107.	Have you ever been placed on court probation as a juvenile or an adult? If yes, give	Yes	No
	details (including dates, where and why.)
108.	Have you ever had a warrant issued for your arrest (including traffic warrants)? If	Yes	No
	yes, give details (including dates, where and why.)
109.	Are you currently, or have you ever been on parole or probation? If yes, give details	Yes	No
	(including dates, where and why.)
	Have you ever been arrested or convicted of any crime, as an adult or juvenile
110.	(excluding traffic citations)? If so, please provide the following information: Date	Yes	No
110.	of incident, police agency, circumstances, sentences, court case number, police case	Yes	No
	number, police reports, and court).
111.	Are you now wanted for any reason by any law enforcement agency?	Yes	No

112.	Have you ever had a criminal record (adult or juvenile) sealed?	Yes	No

113.	Have you ever had to testify in a criminal proceeding?	Yes	No

114.	Have you ever had your vehicle searched?	Yes	No

115.	Have you ever been reported to any law enforcement agency as a runaway or	Yes	No
115.	missing person?	Yes	No
116.	Have you ever been named on or been party to a restraining order?	Yes	No

117.	Have you ever refused to obey a restraining order?	Yes	No

118.	Has your spouse ever called the police on you for any reason?	Yes	No

119.	Have you ever been a victim of gang violence?	Yes	No

120.	Have you ever “tagged” or participated in “tagging” someone else’s property?	Yes	No

121.	Have you ever had a drunk driving arrest reduced to a reckless driving?	Yes	No

122.	Have you ever engaged in any criminal activity using a computer or any other	Yes	No
	communication device?
123.	Have you ever been a victim of a criminal act?	Yes	No

	Have you ever committed any dishonest act in order to obtain a Police Officer
124.	position? (i.e., cheating on written exam, or having another person take your medical	Yes	No
	exam, etc.?)
125.	Have you ever used falsified identification or identification belonging to another?	Yes	No

126.	Have you cheated on a test?	Yes	No

127.	Did you omit from your application any employment issues (i.e., terminations, or	Yes	No
	layoffs)?

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HONESTY

128.	Have you intentionally omitted any fact or facts from your application or withheld	Yes	No
128.	any adverse information from the background investigator?	Yes	No
129.	Have you ever given any confidential information to any organization or individual	Yes	No
	that would jeopardize our national security?
	FRIENDS, ASSOCIATES & FAMILY MEMBERS

130.	Have you ever had any difficulties or disputes with a neighbor?	Yes	No

131.	Has any of your high school, college friends or current associates ever been	Yes	No
131.	convicted of a crime?	Yes	No
132.	Have you ever committed a crime not previously mentioned?	Yes	No

133.	Have you or your family or associates ever violated any law while associating with	Yes	No
133.	members of a street gang?	Yes	No
134.	Have you, your family or associates ever participated in a drive by shooting of a	Yes	No
134.	person, home or vehicle? If yes, what role did you play?	Yes	No
135.	Do you know, or have you or your family members ever knowingly associated with	Yes	No
	any member of a street gang?
136.	Have you ever been a member or participated in any gang activity?	Yes	No

137.	Have you ever attended a gathering of any street gang?	Yes	No

138.	To your knowledge, have any of your immediate family members, friends, or	Yes	No
	associates ever been arrested or are they now involved in any illegal activity?
139.	Have any of your family members or associates ever been placed on probation or	Yes	No
	parole?
	During your background investigation, is anyone likely to report that you have any
140	personality characteristics that would make you unsuitable for the position you have	Yes	No
	applied for?
141.	Do you now or have you ever had any character defects?	Yes	No

	DRUGS AND NARCOTICS

142.	Do any of your friends, immediate family, or associates use any drugs, narcotics, or	Yes	No
142.	other illegal substances? If yes, are you in contact with them?	Yes	No
143.	Have you ever remained in a place where drugs, narcotics or other illegal substances	Yes	No
143.	were being used, possessed, sold, manufactured, etc.?	Yes	No
144.	Have you ever purchased narcotics or drugs, including marijuana, without a doctor’s	Yes	No
144.	prescription?	Yes	No
145.	Have you ever furnished, manufactured, cultivated or possessed any drug, narcotic,	Yes	No
145.	or other illegal substance?	Yes	No
146.	Have you ever knowingly allowed anyone to use illegal drugs in your home?	Yes	No

147.	Have you ever sold narcotics or drugs, including marijuana?	Yes	No

148.	Have you ever worked under the influence of illegal drugs?	Yes	No

149.	Have you ever ingested a substance you thought was an illegal drug and then found	Yes	No
	out it wasn’t?
150.	Have you ever been involved in the manufacturing of any drugs?	Yes	No

151.	Have you ever been the “middle man” for a drug deal?	Yes	No

152.	Have you ever purchased steroids?	Yes	No

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153.	Have you ever helped another person purchase steroids?				Yes	No

154.	Have you or anyone else (other than medical personnel) injected anything into your				Yes	No
154.	body?				Yes	No
155.	If applying for Deputy Sheriff: Would you arrest a friend if you came upon that				Yes	No
155.	friend using narcotics or illegal drugs?				Yes	No
156.	Do you object to other people using illegal drugs or narcotics?				Yes	No

157.	During your background investigation, is anyone likely to report that you have been				Yes	No
157.	involved in the use or sales of illegal drugs?				Yes	No
158.	Have you ever-tested positive on an employment related drug test?				Yes	No


159.	Have you EVER, during the course of your lifetime, used, tried,			Month/Year	Month/Year
159.	experimented, or in ANY WAY ingested into your body:			First Used	Last Used
Marijuana (THC/STP)		Yes	No

Hashish / Hash Oil		Yes	No

Cocaine		Yes	No

Barbiturates (Downers)		Yes	No

Amphetamines (Uppers, Speed)		Yes	No

Heroin		Yes	No

LSD (Acid), Mushrooms, or other Hallucinogens		Yes	No

Peyote or Mescaline		Yes	No

Opium / Morphine		Yes	No

PCP (Angel Dust)		Yes	No

Steroids – Oral or Injectable (Other than prescribed)		Yes	No

Toluene (Inhalants)		Yes	No

Combination of Substances or any “Designer Drug”		Yes	No

Ecstasy, GHB		Yes	No

Any other drug (Other than prescribed)		Yes	No

If you have used any of the listed drugs above or any other illegal drug, you must write a complete explanation in handwriting on the blank sheets attached. Be specific as possible.

TEMPERAMENT

160. Do you frequently lose your temper?		Yes	No

161.	Have you ever lost your temper with your family, friends, co-workers, supervisors, or	Yes	No
161.	a stranger?	Yes	No
162.	Have you ever been involved in a fight? If yes, give details.	Yes	No

163.	In the past year, have you ever been in or started any fights?	Yes	No

164.	Since you were 18, have you struck or injured any person?	Yes	No

165.	Have you ever struck someone living with you?	Yes	No

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166.	Have you had to physically defend yourself? If yes, how many times (other than	Yes	No
166.	training, e.g., military, police academy, or self-defense courses, etc.)?	Yes	No
167.	Other than in warfare, have you ever caused serious injury to a human being?	Yes	No

168.	Other than in warfare, have you ever used any weapon against someone?	Yes	No

	Other than in warfare, have you been involved in a violent incident such as a
169.	shooting, knifing, or fight where someone was, or could have been, seriously injured	Yes	No
	or killed?
170.	Other than in warfare, have you ever caused the death of a human being?	Yes	No

	If applying for Deputy Sheriff: If it becomes necessary in the course of your duties to
171.	take a human life, would you have any reluctance to do so because of religious or	Yes	No
	other personal beliefs?
172.	During your background investigation, is anyone likely to report that you have violent	Yes	No
	tendencies?
173.	During your background investigation, is anyone likely to report that you have a	Yes	No
	problem with your temper?
	Have you ever mentally or emotionally abused someone in an intimate relationship
174.	(i.e. frequently called them harmful names, threatened them, terrorized them,	Yes	No
174.	humiliated them, insulted them, intentionally tried to hurt their feelings, or make them	Yes	No
	feel bad?)
175.	Have you ever been in a physical confrontation with someone in an intimate	Yes	No
175.	relationship (i.e. push, shove, hit, slap, hold, grab, etc.)?	Yes	No
	Have you ever been controlling in an intimate relationship (i.e. told partners what to
176.	wear, whom they could and could not see, when they should be home, how they	Yes	No
	should act, etc.)?

MISCELLANEOUS

177.	Have you ever taken a polygraph? If yes, when and where?	Yes	No

178.	Have you ever been refused a security clearance? If yes, where, when and why?	Yes	No

179.	Have you ever belonged to a subversive or militant group that has advocated the use	Yes	No
179.	of violence or unlawful means to obtain its goals?	Yes	No
180.	Do you have any tattoos? If yes, give description and location.	Yes	No

181.	Have you ever been involved in a hazing incident?	Yes	No

182.	Are there any actions pending in civil court in which you are a defendant?	Yes	No

183.	Is there anything in your background that you have not been asked about that might	Yes	No
	eliminate you from consideration for this job if it were found out?

12	PRE-BACKGROUND INTERVIEW QUESTIONNAIRE.doc

LAW ENFORCEMENT / MILITARY POLICE EXPERIENCE

THOSE APPLICANTS WHO ARE NOW OR HAVE PREVIOUSLY BEEN PEACE OFFICERS, RESERVE PEACE OFFICERS OR MILITARY POLICE OFFICERS MUST ANSWER THE FOLLOWING QUESTIONS.

184.	As a peace officer, have you ever accepted a gratuity?	Yes	No

185.	As a peace officer, have you ever accepted anything for overlooking a violation?	Yes	No

186.	As a peace officer, have you ever made a false official report?	Yes	No

187.	As a peace officer, have you ever used your official position for personal gain?	Yes	No

188.	As a peace officer, have you ever withheld evidence seized in the course of your	Yes	No
188.	official duties.	Yes	No
189.	As a peace officer, have you ever had sex on duty?	Yes	No

FOR THE FOLLOWING QUESTIONS, INCLUDE: DATES, AGENCY’S NAME, NAMES OF OTHER OFFICERS, LOCATION, CASE NUMBERS, AND A CONTACT PERSON IN CHARGE OF THE INVESTIGATION/COMPLAINT.

190.	Have you ever been the subject of an Internal Affairs investigation?	Yes	No

191.	Have you ever had a citizen’s complaint alleged against you?	Yes	No

192.	Have you ever had any disciplinary actions taken against you, including suspensions,	Yes	No
192.	demotions, or written and oral reprimands	Yes	No
193.	Have you ever been involved in an incident where it was necessary to use deadly	Yes	No
193.	force, regardless if the person died or not?	Yes	No

I am aware that any false statements or omissions made on this questionnaire will cause my name to be removed from the eligibility list, or be cause for non-selection by the San Bernardino County Sheriff’s Department. I understand that I am subject to termination if discrepancies are discovered after I have been appointed. Additionally, I understand that I am to immediately notify my background investigator of any changes in the above information. Failure to notify the Sheriff’s Background Unit of these changes could also be grounds for disqualification and/or non-selection.

Print Name: _________________________________________________________

Signature: ___________________________________ Date: __________________

Background Investigator: ______________________________________________

Signature: ___________________________________ Date: ___________________

13	PRE-BACKGROUND INTERVIEW QUESTIONNAIRE.doc

14	PRE-BACKGROUND INTERVIEW QUESTIONNAIRE.doc

15	PRE-BACKGROUND INTERVIEW QUESTIONNAIRE.doc

16	PRE-BACKGROUND INTERVIEW QUESTIONNAIRE.doc

17	PRE-BACKGROUND INTERVIEW QUESTIONNAIRE.doc

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Learn how to fill in California portion 4

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California conclusion process detailed (portion 5)

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